Provider Demographics
NPI:1487130969
Name:AGRAWAL, PRIYATA (DDS)
Entity type:Individual
Prefix:
First Name:PRIYATA
Middle Name:
Last Name:AGRAWAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W 90TH PL APT 305
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6751
Mailing Address - Country:US
Mailing Address - Phone:601-383-0972
Mailing Address - Fax:
Practice Address - Street 1:713 US HIGHWAY 41 STE A
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-293-8039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012997A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist